Oncological Emergencies Flashcards
What are the 4 most common oncological emergencies?
- neutropenic sepsis
- hypercalcaemia
- metastatic spinal cord compression
- superior vena cava obstruction (SCVO)
What is the definition of neutropenic sepsis?
patients having cancer treatment whose neutrophil count is less than 1 x 10^9 per litre and has either:
- a temperature higher than 38 degrees
- other signs and symptoms consistent with clinically significant sepsis
What is the difference between septicaemia and sepsis?
Septicaemia:
this is the presence of a pathogen in the bloodstream, which can lead to sepsis
Sepsis:
systemic inflammatory response syndrome (SIRS) triggered by a primary localised infection
SIRS - clinical signs that occur in response to systemic inflammation
What needs to be present for SIRS or sepsis to be diagnosed?
2 or more of:
1. temperature < 36o or > 38o
2. tachycardia where HR > 90bpm
3. respiratory rate > 20 per min OR PaCO2 < 4.3kPa
4. white cell count > 12 x 10^9or < 4 x 10^9
it is sepsis when there are 2 or more of these signs but they RESULT FROM INFECTION
What is meant by severe sepsis?
sepsis with signs of organ hypo-perfusion
- hypoxaemia
- oliguria
- lactic acidosis
- acute alteration in mental state
What is meant by septic shock?
severe sepsis with hypotension
OR the requirement for vasoactive drugs despite adequate fluid resuscitation
hypotension is systolic BP < 90 or a decrease > 40 from baseline
Why does neutropenic sepsis occur in cancer patients?
- chemotherapy is given to target cancer cells, but it will also target healthy cells
- damage to the bone marrow from chemotherapy results in a drop in neutrophil count
Which patients are at a greater risk of neutropenic sepsis?
it is common with intense chemotherapy regimes:
1. haematological malignancies
2. breast cancer
3. germ cell tumours
How does someone with neutropenic sepsis typically present?
Why is it important to identify this quickly?
- patients will decompensate quickly
- typically, a young patient receiving chemo will present with a temperature but other parameters are normal
- they do not have the neutrophil count to mount the infection so rapidly decompensate
important to identify early as it has a 5% mortality rate
When does neutropenic sepsis typically occur?
it typically occurs between 7 and 14 days post-chemotherapy
it is VITAL to ask patients when they had chemotherapy
What is the typical presentation of someone with neutropenic sepsis?
- they present with being non-specifically unwell
- they may be tachycardic or hypotensive
- they may have a temperature
- they may have localising signs of infection
a temperature can depend on whether they have had paracetamol
Why is it important to perform a head-to-toe examination of anyone presenting with non-specific signs of illness?
to look for localising signs of infection that could be affecting one part of the body
What are common signs of a CNS infection?
- headache
- visual disturbances
- neck stiffness
What are common signs of a respiratory tract infection?
- cough
- shortness of breath
- chest discomfort
Why is it important to inspect the oral cavity in chemotherapy patients?
- some chemotherapy regimes can result in mucositis (sore mouth)
- if the mouth becomes ulcerated, this is a potential route for infection
What question is particularly important to ask chemotherapy patients when it comes to a potential source of infection?
do they have a central venous catheter in place?
the area of the line must be assessed for signs of redness and discharge
this could be a PICC line in-situ, Hickman line, central line or portacath
What symptoms may suggest a GI tract infection?
- abdominal pain
- diarrhoea
Which patients are more likely to have stents in place and what symptoms might infection produce here?
Biliary stents (liver malignancy):
infection may produce RUQ pain or rigors
Ureteric stents:
infection may produce flank pain, dysuria, haematuria + frequency
What are the 4 most important areas to cover in a neutropenic sepsis history?
- chemotherapy drugs and TIMING + any access / lines
- previous episodes
- presence of localising symptoms
- any allergies
What is involved in the physical examination for suspected neutropenic sepsis?
- temperature + circulatory status (ABC)
- NEWS score
- full systematic examination (cardiovascular, respiratory + abdominal)
- focus on potential sites of infection (lines / catheters / perianal area)
- review previous + recent microbiology for resistant organisms
What is meant by the A-E approach for a potential septic patient?
A - airway
B - breathing
C - circulation
D - disability
E - exposure
if one or more red flag is present during any stage, the patient should be treated for sepsis
What red flags may be identified during the breathing stage of assessment?
- RR >/= 25 breaths per minute
- O2 required to keep SpO2 > 92%
What red flags may be identified during the circulation stage of assessment?
- tachycardia > 130 bpm
- systolic BP < 90 or a drop of 40 from normal
- lactate >/= 2 mmol/l
What red flags may be identified during the disability stage of assessment?
- acute confusional state
- responds only to voice or pain or unresponsive
V, P and U in the AVPU scale
What red flags may be identified during the exposure assessment?
- non-blanching rash
- mottled, ashen or cyanotic apperance
- urine output < 0.5 ml/kg/hour
What should be done if any red flag symptoms are present?
- B - blood cultures
- U - measure urine output
- F - IV fluids
- A - broad spectrum antibiotics
- L - measure lactate
- O - high-flow oxygen
SEPSIS 6 performed within 1 hour (BUFALO)
What is an alternative way of remembering the sepsis 6?
- take blood cultures, give IV antibiotics
- take urine output, give IV fluids
- take lactate, give high-flow oxygen
the take 3 / give 3 method
What blood samples are useful in a patient with signs of neutropenic sepsis?
- FBC - to look at the neutrophil count and for signs of anaemia
- inflammatory markers - CRP and lactate
- LFTs to assess liver function
- assessment of hepatic function to determine if patient is dehydrated
What blood cultures are taken?
- x2 paired blood cultures are taken (aerobes & anaerobes)
- if a line is present then 1 is taken from this and 1 from the periphery
- if the patient does not have a line, then 2 peripheral samples are used
What additional investigations may be performed depending on presentation?
- swabs are taken from any area that shows a discharge
- sputum culture
- urine analysis and culture
- stool analysis and culture (if diarrhoea)
- CXR if respiratory signs / symptoms
What are the NICE guidelines for treatment of suspected sepsis?
broad spectrum IV antibiotics must be given within 1 hour of all suspected cases
allergy status must be assessed and cannula in-situ before abx started within 1 hour of initial presentation
Following IV abx, what other management steps are in place?
- give IV fluids if patient is hypotensive or tachycardic
- strict fluid balance with monitoring of input and output
- escalate to oncology SPR
What is the difference in treatment for patients with suspected sepsis that are having palliative chemotherapy?
- often they will not want to spend a lot of time in hospital
- abx are given until the patient is proven not to be neutropenic
- if the patient is neutropenic, the duration of antibiotics depends on their MASCC score
What is the MASCC score?
- assesses the risk of complications during a febrile neutropenic episode
- the score works out when abx can be de-escalated and a palliative care patient can be sent home on oral abx
multinational association for supportive care in cancer patients
What parameters does the MASCC score consider?
- infection burden
- co-morbidities
- age > 60
- blood pressure
- presence of COPD
- tumour type - haematological / solid
- fluid status
- in-patient / out-patient
the lower the score, the lower the risk of a poor outcome
What is G-CSF?
they are haematopoitic growth factors that promote stem cell proliferation and shorten the duration of neutropenia
G-CSF agents are Filgrastim or Lenograstim
this does NOT mean that the patient will not be neutropenic
it shortens the duration of the neutropenia, meaning it is less likely to contract an infection during this time
When is G-CSF given to a patient?
it is NOT routinely prescribed
- it is given to patients on chemotherapy regimes with high risk of neutropenia
- or if they have had a previous episode requiring hospitalisation
- or multiple co-morbidities / severe sepsis
Describe normal calcium homestasis when there is a high blood calcium level
- the thyroid gland releases calcitonin when blood calcium is too high
- calcitonin promotes the osteoblasts to deposit calcium within the bone
- calcitonin reduces absorption of calcium in the kidneys
- this results in a decline in blood calcium levels
Describe calcium homeostasis when blood calcium is too low
- the parathyroid gland releases PTH
- PTH promotes osteoclasts to release calcium from the bones
- PTH stimulates the kidneys to absorb calcium from the urine
- the kidneys convert 25-hydroxy Vitamin D to dihydroxy Vitamin D - this stimulates the bowels to absorb calcium
In general, why does hypercalcaemia occur in malignancy?
due to factors produced by tumours which increase bone resorption and potentially increase renal tubular calcium reabsorption
these are transforming growth factor alpha + parathyroid hormone (PTH) related peptides
What is transforming growth factor alpha and how does it work?
- it is a polypeptide stimulator of cell growth and replication that is produced by many cancer cells
- it is a powerful stimulator of bone resorption
How do PTH-related peptides work?
- it is a tumour-associated protein that mimics PTH
- it stimulates bone resorption and increases plasma calcium
What malignancies are commonly associated with hypercalcaemia?
- it is common in cancers that have bone mets and in tumours that secrete PTH-RPs
this includes:
- lung cancer (NSCLC)
- prostate cancer
- breast cancer
- renal cell carcinoma (often secretes PTH-RPs)
- myeloma + lymphoma
What are the general symptoms of hypercalcaemia?
- dehydration
- muscle weakness
- fatigue
- bone pain
What are the CNS symptoms of hypercalcaemia?
- confusion
- seizures
- proximal neuropathy
- hyporeflexia
- coma
What are the GI tract symptoms of hypercalcaemia?
- weight loss
- N & V
- abdominal pain
- constipation
- ileus
- dyspepsia
- pancreatitis
What are the cardiac symptoms of hypercalcaemia?
- bradycardia
- arrhythmia
- cardiac arrest
What is the most common ECG finding in hypercalcaemia?
bradycardia with a short QT interval
wide T waves + prolonged PR interval can also be seen
What is the management for mild hypercalcaemia?
when Ca is < 3.0 mm/l then management involves rehydration with IV fluids
What is the treatment for more severe hypercalcaemia?
when Ca > 3.0mm/l OR patient is symptomatic:
- at least 3L of sodium chloride is given BEFORE
- bisphosphonate treatment
- thiazide diuretics MUST be STOPPED and furosemide is considered
What bisphosphonates may be given in hypercalcaemia?
What else must be done?
- usually Zometa 4mg IV is given
- pamidronate 60 - 90mg is considered if there is a decline in renal function
- patient MUST be rehydrated with 3L sodium chloride prior to bisphosponate therapy
renal function MUST be monitored when patient is given bisphosphonat
When might calcitonin be considered in hypercalcaemia?
- if calcium levels are VERY high, patient is considerably symptomatic and there are concerns about tachyphylaxis
a decrease in response to a drug after it is initially given
would still try to initially manage with IV fluids and bisphosphonates
What are the 10 red flag symptoms when someone presents with back pain?
- age < 20 or > 50
- trauma
- weight loss
- pyrexia / night sweats
- leg weakness
- sensory loss of LL
- thoracic back pain
- constant pain at night and at rest that doesn’t respond to analgesia
- urinary retention / faecal incontinence
- saddle anaesthesia / loss of anal tone
What is shown in this image?
metastatic spinal cord compression (MSCC) at T10
the vertebra is affected by the tumour and the CSF (white layer surrounding SC) is not evident at this level
How common is MSCC?
Which cancers does it usually occur in?
- it is the most common neurological complication of cancer
- occurs in 5% of all cancers
- most common in breast, prostate, lung and haematological
What are the different mechanisms by which MSCC can occur?
- soft tissue can infiltrate the spinal canal
- cancer can compress the vertebrae and lead to bony prominences compressing the spinal canal
- via drop mets - these are metastases that enter the CSF space
How does MSCC usually present?
- if the lesion is above L1 - patient presents with UMN symptoms
- if the lesion is below L1 - patient presents with cauda equina
- 60% of patients will have pain
What are the key features of an UMN lesion?
- no muscle wasting (except for disuse atrophy)
- “clasp-knife spasticity” / hypertonia
- clonus present
- hyperreflexia
- positive Babinski sign
What are the key features of a LMN lesion?
- flaccid paralysis
- decreased reflexes
- presence of fasciculations (twitching)
- decreased muscle tone
- muscle atrophy
- negative Babinksi sign
What are the typical symptoms of cauda equina syndrome?
- severe back pain
- bilateral sciatica
- perianal “saddle” anaesthesia
- bowel / bladder dysfunction (most commonly urinary retention)
- sexual dysfunction
If someone presents with any of the red flag back pain symptoms what must be immediately done?
an urgent MRI of the whole spine
What is the treatment pathway for suspected MSCC?
- 16mg dexamethosone with PPI cover
- urgent MRI of whole spine within 24 hours
dexamethasone is a steroid that can aid with removing some oedema and decompressing the spinal cord prior to intervention
If MRI comes back as positive for MSCC, what are the next steps?
- neurosurgical intervention is considered for eligible patients
- radiotherapy is an alternative option
When is someone with MSCC considered for surgery?
- MRI shows a single area of vertebral collapse / SCC with no other metastatic disease throughout the spine
- patient has good performance status
- predicted survival greater than 3 months
- not paraplegic for more than 48 hours
When is radiotherapy typically used for MSCC?
- when multiple areas of the spinal canal are affected
- poor performance status
- poor prognosis of < 3 months
palliative radiotherapy can improve motor function + symptoms
What are the side effects associated with radiotherapy for MSCC?
- pain flare
- nausea
- vomiting
- diarrhoea
- tiredness
Why is it important to perform radiotherapy quickly when suspecting MSCC?
57% of patients will regain the ability to walk again if treated within 24 hours
if all motor function is lost for 48 hours, then recovery is unlikely
What is meant by superior vena cava obstruction (SVO)?
obstruction to the superior vena cava blood flow by external compression, thrombosis or direct invasion of the SVC
this restricts blood return to the heart from the head, neck and UL
What are the characteristic symptoms of SVCO?
- swelling of the face / neck / arms
- distended veins across the neck + chest
- breathlessness
- headache (worse on coughing)
- cyanosis
- visual disturbances
What is the first-line investigation for suspected SVCO?
CXR
this gives the ability to identify mediastinal widening and may show the primary cause of SVCO
CXR is normal in 16% patients with SVCO
mediastinal widening = width > 8cm on PA view
Following CXR, what investigation would be performed for SVCO?
high-resolution CT / CT with contrast
this allows you to identify the underlying cause and the extent to which the disease has progressed
Why is it important to perform both a CXR and CT in SVCO?
- this allows you to identify whether obstruction is from an external cause or internal (thrombus)
- management depends on the cause
What are the most common malignant causes of SVCO?
- lung cancer
- lymphoma
- mediastinal lymphadenopathy
- germ cell tumours
- thymomas
- oesophageal cancer
- tumour associated thrombus (as a result of hypercoaguability)
these are all cancers affecting the mediastinum / central chest
What are the most common benign causes of SVCO?
- non-malignant tumours (goitre)
- mediastinal fibrosis - idiopathic / post-radiotherapy
- infection - TB
- aortic aneurysm
- thrombus associated with indwelling catheters
What is the first step in treatment for SVCO?
16mg dexamethasone with PPI cover
this is performed whilst awaiting CT results
After CT results, what are the potential treatment options for SVCO?
- vascular stent if cause is external compression + patient decompensated
- radiotherapy / chemotherapy - if cancer would respond quickly to these
- anticoagulation with LMWH if thrombus is confirmed
